Weekends at Bellevue (3 page)

Bellevue is the oldest public hospital in the United States, with a long tradition of “serving the underserved.” Its origins date back to a six-bed infirmary which opened in 1736. Bellevue has been an almshouse, a penal institution, and most infamously, an asylum: In 1878, a dedicated pavilion for the insane was christened. The world’s first hospital
ambulance service, maternity ward, pediatric clinic, and emergency room all got their start right here, but it’s the asylum that gets remembered, the ultimate symbol of bedlam that is most strongly yoked to Bellevue’s name.

“Take him to Bellevue,” is the line I remember best from the old TV cop show
Barney Miller
. It was Hal Linden’s answer for any arrestee who was off his rocker. I remember watching that show and wondering,
Where is this magical place?

I spent my adult life insatiably educating myself on insanity and its treatment, and as soon as I could get a job there, I did.

T
he doors whoosh open automatically as I walk into the ambulance bay by the medical ER, called the AES (for Adult Emergency Services). I say hello to the hospital police officers who are stationed here. Bellevue employs nearly eighty of their own cops, and I get to know all of them over the years as their positions rotate through the various security desks and entrances of the buildings. When there is a ruckus in the psych ER and the staff needs more hands on deck, “HP!” is our SOS. The hospital police hear “HP to CPEP” over their walkie-talkies and come running, stopping briefly to put on a pair of gloves before jumping in to restrain an agitated patient.

The back hallways leading from the AES to the CPEP are interrupted by multiple sets of double doors. Off the hall to the right is the radiology suite, where chest X-rays and CT scans are performed. On the left is “the blue room,” the holding area for prisoners who have been treated and released and are waiting for the bus to take them back to Rikers Island. When the prison guards amass a busload on Monday mornings, the prisoners, dressed in orange jumpsuits, their hands and legs shackled, will make their way through these back hallways toward the rear exit, where a bus is idling. It is the most abject, sorrowful group of men you will ever see. They are captive and sick, suffering physically as well as mentally. Many are in withdrawal from whatever was keeping them going on the outside. Others have swallowed taped-up razor
blades or lightbulbs in an effort to leave the prison and be admitted to the hospital.

While the procession slowly makes its way toward the back door, two corrections officers at either end hold up the traffic, forcing all the Bellevue staff in the corridor to wait until the prisoners have left. The Rikers inmates march right by the entrance to CPEP. When I first started at Bellevue, I was callous, posturing with bravado while I stood there watching them pass. Sometimes I’d even whistle “I Love a Parade” as they went by. Over the years, my demeanor has softened; now, when the prisoners troop by, I am silent and respectful, offering a sympathetic smile, saying “Hey” if I catch anyone’s eye.

Across the hall from the CPEP entrance, there is a suite of offices and call-rooms. Call-rooms are places where doctors can theoretically sleep during the nights they spend “on-call,” in the hospital. My first call-room at Bellevue was small and cold, with a rock-hard, narrow bed. When the CPEP moved to its new location, one year after I arrived, I got a larger office. When I got pregnant a few years later, I splurged for a queen-sized bed. It is the largest in the hospital, as far as I know.

As I walk into my call-room, all the way in the back corner of the suite, I throw my things on the bed and check my voice mail before gathering my belongings for the shift. CPEP keys go in the tiny front-right pocket of my jeans; I call this the drug pocket, because it’s where patients tend to stash their favorite pills, baggies of dope, or crack vials. My Bellevue ID gets clipped to my scrub top, as does one black pen. My beeper clips to the waistband of my jeans. I grab a water bottle, and my clipboard and folder (stuffed with reference material, like how long cocaine metabolites stay positive in urine samples and how many milligrams of Xanax equal a similar dose of Valium), and head for the door.

My hair is still wet from the shower I took before I left my apartment as I walk through the patient waiting area. On one side of the room, six green leather bucket seats are connected by a metal bar. Above the chairs, pictures of flowers framed in plastic are bolted to the wall.

The hospital police officer assigned to this area sits at a desk with a patient log book. If he’s not writing an entry, he may be reading a magazine or watching a portable DVD player, but more likely he is shooting the breeze with a real cop from the NYPD. These guys love to tell war
stories, trying to outdo each other with the most outrageous or horrifying narratives.

Once a patient has been logged in by HP and then registered by the clerk, who sits like a bank teller behind Plexiglas, he is sent to see a nurse in the triage room, a windowed cell that separates the patient waiting area from the nurses’ station. My own progress through CPEP mirrors the journey the patients take, and I greet the hospital police officer, the clerk, and the triage nurse as I pass each one. I use my key to enter the main area of the psych ER, the locked detainable area, noting the noise, the smell, and the level of activity that will surround me for the next dozen hours or so.

Once I’m in the nurses’ station within the locked area, the first thing I need to know to get the ball rolling is the census. How many patients are on hold, admitted, or waiting to be seen? How many of the admissions have been assigned to a bed upstairs and how many will remain in CPEP because the inpatient units have filled up? My biggest concern is back-up on either end. Is the waiting area full of patients yet to be seen, or is the locked detainable area crowded with stalled admissions? Priority one is to keep the census down.

Priority two is to get NYPD out of our waiting area. They have brought their prisoners to be evaluated prior to arraignment, and we need to help make it as brief a detour as possible. Bellevue has a job to do for the city, assisting NYPD in keeping their prisoners safe. Any arrested person who has a psychiatric history or is taking psych meds (this includes the Upper West Side mom on Prozac caught shoplifting) needs to be screened by us. If the police suspect that their prisoner is suicidal, they’ll bring him to Bellevue for screening, because it’s not safe to leave a potential suicide alone in a cell. Sometimes, a prisoner is so grossly psychotic that it is inappropriate for him to be held in police custody. Ever since one deranged man at central booking—who was never referred for a psych evaluation—stepped on another’s neck and killed him, we have been screening more prisoners than ever.

Whenever an arrested person is brought to Bellevue, the job of the psychiatrist is well circumscribed. It is only to ascertain if the patient is calm enough to stand in front of a judge and be arraigned, and whether there is an acute risk of self-harm or danger to others while in police custody. This is called a pre-arraignment evaluation. It is not my
responsibility to determine the patient’s capacity to stand trial, and it is certainly not my place to judge guilt or innocence.

If a prisoner requires an admission, he is sent to 19 West, the forensic unit. The other inpatient units occupy multiple floors and wings. 20 South is the unlocked detox ward for voluntary patients only. All the other psych wards are locked, even though they house a mixture of voluntary and involuntary patients. 20 East is a dual diagnosis ward for psychiatric patients with alcoholism or drug addiction, the bulk of our clientele. 20 North is the geriatric unit. 18 South has Mandarin-and Cantonese-speaking staff for our Asian immigrant patients. 19 North is the teaching unit for particularly interesting or complicated cases. 12 South is the med/psych unit for those in need of intravenous medication or other intensive medical treatments.

Many of the patients are eligible for more than one unit, but I can only send them up if I know there are empty beds waiting for them. The nurses upstairs don’t like new patients coming in over the weekend, so they play games with their own census data, making it seem as though they couldn’t possibly take one more patient. Then on Sunday night, sure as the
60 Minutes
clock will tick on CBS, the “mystery beds” miraculously open up, and there is a merciful drainage of our area. The problem is, this relief valve is usually nowhere in sight when I arrive on Saturday night.

But there are other options: I don’t have to admit all the patients upstairs. We have our own six-bed ward, the EOU (Extended Observation Unit), where we can place a patient for up to seventy-two hours on a 9.40, an involuntary admission that gives us up to three days to figure out what’s going on with the patient, which ideally involves speaking to family members, employers, and therapists. During their stay, we can see if there’s any change in presenting symptoms. Once the time is up, we need to either discharge or admit. We can admit by using either a 9.39, an involuntary admission, or if the patient is willing to sign in voluntarily, a 9.13. All the “9 point something”s require a set of New York State legal papers to be placed in the chart.

If I’m not sure where to place a patient, I have an easy out—a twenty-four-hour Hold requires no legal status, no justification for detainment. Patients spend the night and are reinterviewed in the morning when they’re less drunk, high, or sedated. The Hold is the
disposition of last resort. It is better for patients to have a definitive status, but sometimes, when they can’t give any coherent information, that’s impossible. The patients who are safe to be discharged from the CPEP are the T & R’s: They are treated and released. They’re not sick or dangerous enough to keep hospitalized, so we patch them up and send them back to the front, just like they did on
M*A*S*H
, only our war zone is the mean streets of New York.

Sometimes patients are eager to leave, but other times they mostly want a place to sleep. Occasionally they’ll ask earnestly if they can please just spend the night; other times they’ll manufacture symptoms in order to dupe me. Either way, I utter my well-rehearsed line, “This isn’t a shelter, it’s a hospital; you need to be genuinely sick to stay here.” The Bellevue men’s shelter is just one block north, and many of our discharged patients are referred there, though they are loath to go.

There’s an oddball category of patients with no official status that I call “Waiting for Laces.” This is a T & R whose discharge paperwork is still pending, sitting in the nondetainable area waiting to speak with a social worker about what we call the “dispo plan”—where to go next and how to follow up with outpatient services. It’s a tense, vulnerable position to be in, having been judged sane enough to leave the hospital, but still in limbo while you wait for your walking papers and your belt, shoelaces, and wallet, knowing you need to stay calm and polite in order to be released. Some of these patients are furious at being discharged. They would rather be admitted to Bellevue than sleep on the steaming sidewalk grates or in the subways or shelters. Sometimes they’ll make a scene, threatening the staff and requiring hospital police to escort them off the grounds, perhaps without all of their belongings. (When I see the laceless walking the streets of the city, I wonder if they are people who got tired of waiting for the social worker and just left without picking up their belongings, or if they were never actually deemed safe to be discharged but have somehow managed to escape.)

After I have figured out how many patients are in the CPEP and where they’re likely to end up, I see how the staffing looks. Do I have any medical students rotating through here tonight? How many residents are here, and are they first-years or second-, slackers or stars? Most important is which attending—which doctor in charge—has
been working the shift that immediately precedes mine. This will establish whether I have a mess to clean up or whether things have been left in pretty good shape. Sign-out is the changing of the guard between the attendings. It will occur whenever the departing doctor has the time to sit down and run the list, discussing every patient in the area. Often, there are many loose ends to tie up before that can happen.

A busy Saturday night for me is twenty-five or more patients in the CPEP, or more than five on triage. If there are a lot of triages, I won’t wait for sign-out. I will just “glove up and dig in,” as they say in medicine. (This saying is medical jargon for manually dis-impacting a constipated patient, but it has morphed into meaning “suck it up and get to work.”) I will grab a chart and see any patient who has already been triaged by a nurse and looks like he could be a quick T & R, which only involves writing up the interview and a discharge order, considerably less paperwork than the other dispo plans, since there are no legal forms or admission orders to fill out.

When it is less busy, the first order of business is, “When’s dinner and where are we ordering from?” This was especially true during the months at Bellevue when I happened to be pregnant and took “eating for two” very seriously.

The nights tend to progress smoothly. The on-call resident and medical students see the triages, and then present the cases to me. I help them decide who stays and who goes, and I check over all the paperwork to make sure the admissions get packaged for transfer to the upstairs wards. By one a.m., I usually turn in, letting the resident run the show in my absence. I am available for phone calls and consultations, both by the second-year resident in the CPEP and the third-year who is doing consultations upstairs in the rest of the hospital. The attendings in the medical ER often call me as well, to let me know they’re sending someone over to CPEP. I usually sleep about five hours or so, though it is interrupted by multiple phone calls, and occasionally I need to go across the hall to deal with some problem or fill out restraint orders that require an attending’s signature.

I don’t usually eat like a lumberjack, but on Sunday mornings I make an exception. It’s the middle of my Bellevue weekend, and I like to treat myself. Short stack, two eggs over easy on the side, sausage split. I’ve developed little traditions as the years have gone by, and the men behind the counter at the Bellevue coffee shop, with their easy grins and
mischievous eyes, have kept up with my preferences. Their pancakes are legendary among the ambulance drivers and police officers, and their prices are so low even the panhandlers can sit down to a good meal.